STEVEN SPROWL v. COMMISSIONER OF SOCIAL SECURITY (2025)

ORDER

This order concerns Plaintiff Steven Sprowl's request for review of the administrative denial of his application for a period of disability and disability insurance benefits (“DIB”). (Tr. 14.) By this appeal Plaintiff argues the administrative law judge (“ALJ”) erred by improperly ignoring two state agency medical consultants' opinions and by failing to develop the record and making a residual functional capacity (“RFC”) determination without the assistance of any medical opinion.

On June 6, 2025, the Court held a hearing on the merits of Plaintiff's case, at which counsel for both parties appeared via videoconference. After considering Plaintiff's Brief [#10], Defendant's Brief [#14], Plaintiff's Reply Brief [#16], the transcript (“Tr.”) of the Social Security Administration (“SSA”) proceedings [#7], the appliable case authority and relevant statutory and regulatory provisions, the parties' oral argument at the Court's hearing, and the entire record in this matter, the Court concludes that the decision of the Commissioner that Plaintiff is not disabled should be vacated and this case remanded for further proceedings.

I. Jurisdiction

This Court has jurisdiction to review a decision of the Social Security Administration pursuant to 42 U.S.C. § 405(g). The undersigned has authority to enter this Order pursuant to 28 U.S.C. § 636(c)(1), as all parties have consented to the jurisdiction of a United States Magistrate Judge [#6].

II. Legal Standards

In determining if a claimant is disabled, the Commissioner uses a sequential, five-step approach, which considers whether: (1) the claimant is currently engaged in substantial gainful activity, (2) he has a severe impairment, (3) the impairment meets the severity of an impairment enumerated in the relevant regulations, (4) it prevents the claimant from performing past relevant work, and (5) it prevents him from doing any relevant work. Garcia v. Berryhill, 880 F.3d 700, 704 (5th Cir. 2018). If the claimant gets past the first four stages, then the burden shifts to the Commissioner on the fifth step to prove the claimant's employability. Id. (citing Perez v. Barnhart, 415 F.3d 457, 461 (5th Cir. 2005); Newton v. Apfel, 209 F.3d 448, 453 (5th Cir. 2000)). A finding that a claimant is not disabled at any point in the five-step review is conclusive and terminates the analysis. Id. (citing Chaparro v. Bowen, 815 F.2d 1008, 1010 (5th Cir. 1987)); see also 20 C.F.R. § 404.1520(a)(4).

In reviewing the denial of benefits, the Court is limited to a determination of whether the Commissioner, through the administrative law judge's decision,¹ applied the proper legal standards and whether the Commissioner's decision is supported by substantial evidence. Martinez v. Chater, 64 F.3d 172, 173 (5th Cir. 1995); 42 U.S.C. §§ 405(g), 1383(c)(3). “Substantial evidence is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Villa v. Sullivan, 895 F.2d 1019, 1021–22 (5th Cir. 1990) (quoting Hames v. Heckler, 707 F.2d 162, 164 (5th Cir. 1983)). The Court may not reweigh the evidence or substitute its judgment for that of the Commissioner. Newton, 209 F.3d at 452. Conflicts in the evidence and credibility assessments are for the Commissioner, not the Court, to resolve. Id. While substantial deference is afforded the Commissioner's factual findings, the Commissioner's legal conclusions and claims of procedural error, are reviewed de novo. See Greenspan v. Shalala, 38 F.3d 232, 236 (5th Cir. 1994); Cook v. Heckler, 750 F.2d 391, 392–93 (5th Cir. 1985) (citing Hernandez v. Heckler, 704 F.2d 857, 859 (5th Cir. 1983); and then citing Bormey v. Schweiker, 695 F.2d 164, 168 (5th Cir. 1983)).

If the Court does find an error in the ALJ's decision, it will only remand if the claimant has also met his burden of showing that the error was prejudicial. Jones v. Astrue, 691 F.3d 730, 734 (5th Cir. 2012) (citing Audler v. Astrue, 501 F.3d 446, 448 (5th Cir. 2007)). The Court will affirm if the error was harmless. Id. at 734–35. Harmless error occurs “when it is inconceivable that a different administrative conclusion would have been reached even if the ALJ did not err.” Keel v. Saul, 986 F.3d 551, 556 (5th Cir. 2021) (citing Frank v. Barnhart, 326 F.3d 618, 622 (5th Cir. 2003) (per curiam)).

III. Factual and Procedural Background

This is an appeal of a denial of an application for a period of disability and DIB, which Plaintiff applied for in July 2020. (Tr. 14, 208.) He was 42 years old (younger individual) on his alleged onset date of October 1, 2017, and 48 years old (younger individual) on the date last insured, September 30, 2023. (Tr. 22, 75.) The conditions upon which he based his claim are neuropathy, sleep apnea, migraines, acid reflux, arthritis, back problems, shoulder problems, tinnitus, knee problems, and anxiety. (Tr. 75.) There is also a diagnosis of depression in his medical records. (Tr. 76, 80.) He has past relevant work as a decontaminator,² which is classified as medium work. (Tr. 21, 64.) The Veterans Administration determined in 2020 that Plaintiff has a 100% service-connected disability. (Tr. 326.)

In November 2021, Dr. Karlen Moore completed a psychological consultative exam of Plaintiff. (Tr. 2687–2703.) She opined that Plaintiff “likely does not have significant impairment in his ability to understand, remember, and apply information” and that he “likely does not have impairment in his ability to learn, recall and use information.” (Tr. 2702.) She determined he “likely has mild impairment in his ability to relate to supervisors, coworkers, and the public due to transient depression and social withdrawal and transient anxiety” and “is likely to experience mild impairment in emotional regulation related to transient depressive and anxious symptoms.” (Tr. 2702.) He also likely has “mild to moderate” impairment in concentration due to transient/intermittent anxiety and moderate impairment in his ability to persist towards task completion during depressive episodes. (Tr. 2702.)

In December 2021, an initial-level state agency medical consultant (“SAMC”) and state agency psychological consultant (“SAPC”) found that Plaintiff's depressive/bipolar/related disorder is severe, that his migraines are severe, and that he is moderately limited in two of the four areas of the psychiatric review technique (“PRT”),³ including his abilities to concentrate and adapt. (Tr. 77.) The SAPC also determined that Plaintiff is moderately limited in his “ability to respond appropriately to changes in the work setting,” in his “ability to set realistic goals or make plans independently of others,” and in his “ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods.” (Tr. 80.) The state agency consultants stated that his physical RFC limits him to light work and his mental RFC limits him to semi-skilled work. (Tr. 78, 81.) SSA thus denied his claims at the initial administrative level in December 2021. (Tr. 74.)

In December 2022, the reconsideration-level SAMC/SAPC each stated that there is insufficient evidence to recommend a physical RFC or mental RFC,⁴ though they agreed with the initial-level consultants that his depression and migraines are severe. (Tr. 86–88.) The reconsideration-level SAMC also appeared to find that his physical RFC limits him to light work, despite stating that she could not determine his “current functional status” or “residual functional status” due to insufficient evidence. (Tr. 86, 89.) SSA subsequently denied his claims upon reconsideration in December 2022. (Tr. 83.)

Following the denial of his claim, Plaintiff requested a hearing before an ALJ. (Tr. 113.) The hearing was held telephonically before ALJ Gordon Momcilovic. (Tr. 31, 34.) Plaintiff was represented by an attorney, and a vocational expert (“VE”), Calvin Turner, appeared. (Tr. 31, 63.) Prior to the hearing, Plaintiff's attorney at the administrative level requested a neurological and orthopedic consultative evaluation. (Tr. 36.) ALJ Momcilovic denied that request because (1) “it didn't comply with HALLEX regulatory provisions” about consultative examinations; (2) “there are no ambiguities or inconsistencies in the record ․ requiring a resolution via consultative evaluation”; (3) “[a]ny attempts to obtain a [consultative examination] would . . lead to an unjustified postponement of adjudication of this matter ․ [and] also some sort of a fishing expedition”; and (4) any consultative examination in 2024 “would be of questionable probative value” because it is “well over two years after [Plaintiff's date of late insured] expiring.” (Tr. 36– 37.) ALJ Momcilovic noted, however, that there was the possibility he would change this decision and order a consultative examination if warranted. (Tr. 37.)

During the hearing, Plaintiff testified at the hearing that his “short-term memory is really horrible.” (Tr. 48.) He has shortness of breath caused by his sarcoidosis; to treat his sarcoidosis, he uses a nebulizer three times a day, which takes twenty minutes each time. (Tr. 50–52.) His sleep problems cause him to nap for about four hours per day. (Tr. 53.) Once or twice a week his neuropathy causes extreme pain in his face, which requires him to lay down and take gabapentin. (Tr. 54.) His back hurts after sitting for an hour due to degenerative disc disease. (Tr. 55–56.) His migraines occur once or twice per month and are “debilitating.” (Tr. 56–57.) His acid reflux causes him to throw up almost every day after a meal, and he has tinnitus three to four times per week, which causes him to have trouble hearing. (Tr. 58, 60–61.)

The VE at the hearing testified that for an individual of Plaintiff's age, education, and relevant past work, if the individual was limited to light work with the additional limitation of no more than occasional exposure to pulmonary irritants, Plaintiff could not do his past work. (Tr. 64–65.) According to the VE, such an individual could, however, be an office helper, small products assembler, or merchandise marker; these are light, unskilled jobs. (Tr. 65–66.) If this same individual was also limited to understanding, remembering, and carrying out detailed but not complex tasks, these same three jobs would still be available and in the same numbers nationally. (Tr. 66.)

In response to questioning by Plaintiff's attorney, the VE answered that such an individual could not maintain employment if they went off task more than 15% of the time or if they missed work two or more days per month. (Tr. 67.) The VE also stated that a person in an unskilled job could not maintain employment if they needed to leave their work area three times a day for twenty minutes to use a nebulizer or if they consistently could not understand instructions due to tinnitus. (Tr. 68–71.)

The ALJ issued an unfavorable opinion on May 2, 2024, after applying the five-step sequential analysis required by the SSA regulations. (Tr. 14–23.) At step one, the ALJ found Plaintiff last met the insured status requirements of the Social Security Act on September 30, 2023. (Tr. 16.) Plaintiff did not engage in substantial gainful activity during the period from his alleged onset date through his date last insured. (Tr. 16.) At step two, the ALJ found through the date last insured, Plaintiff had severe impairments of pulmonary sarcoidosis with a history of bilateral hilar adenopathy and refractory GERD. (Tr. 17.) His vocal cord paralysis and dysphonia were non-severe because surgery corrected this problem. (Tr. 17.) His sleep apnea was non-severe because the evidence shows that a CPAP machine effectively treats those symptoms. (Tr. 17.) His obesity, degenerative disc disease, osteoarthritis of the feet, and diabetes were also non-severe. (Tr. 17.)

As to mental impairments, the ALJ determined that Plaintiff's depression and anxiety were non-severe.⁵ (Tr. 17.) The ALJ also found that he had mild limitations in three of the four functional areas of the PRT. (Tr. 17–18.) This included a mild limitation in his ability to concentrate, his ability to interact with others, and his ability to adapt. (Tr. 18.) Because these impairments caused no more than mild limitations in any of the functional areas and “there is no more than a minimal limitation in [his] ability to do basic work activities,” his mental impairments were non-severe. (Tr. 18.)

At step three, the ALJ concluded that Plaintiff does not have a listed impairment. (Tr. 18.) Prior to step four, he determined that through the date last insured, Plaintiff had the RFC to perform light work with the additional limitation of no more than occasional exposure to concentrated pulmonary irritants. (Tr. 19.) In making this decision, the ALJ noted that Plaintiff's pulmonologist started treatment for sarcoidosis in January 2022, and in March 2022, he told his pulmonologist he “felt ‘much better.’ ” (Tr. 20.) In 2023, he was diagnosed with mild restrictive airway disease, but he felt better so long as he took his sarcoidosis medication. (Tr. 20.) When he took his medicine, he had improved energy and did not have shortness of breath at rest, though he did still have shortness of breath with exertion. (Tr. 20.) The ALJ stated that the medical evidence therefore supports that Plaintiff can perform light work but cannot have more than occasional exposure to concentrated pulmonary irritants. (Tr. 20.)

The ALJ also reviewed the medical evidence relating to Plaintiff's GERD. (Tr. 20–21.) Plaintiff was diagnosed with gastritis and esophagitis in 2020. (Tr. 21.) Based on the evidence that Plaintiff told his physician that his acid reflux symptoms had significantly improved since he started taking pantoprazole twice per day, the ALJ found that Plaintiff can perform light work. (Tr. 21.)

The ALJ then discussed the psychological consultative exam report completed by Dr. Karlen Moore in November 2021. (Tr. 21, 2687–2703.) The ALJ found Dr. Moore's opinion to be partially persuasive. (Tr. 21.) The ALJ stated that it was “generally persuasive but for [Dr. Moore's] opinion regarding the claimant's ability to concentrate and persist in task completion.” (Tr. 21.) Because the mental status exam findings noted by Dr. Moore and Plaintiff's treating physicians were normal, and Plaintiff had only intermittent anxiety and depression, the ALJ stated that Dr. Moore's finding of “mild to moderate” impairment in concentration is inconsistent with the evidence. (Tr. 21.)

Finally, the ALJ reviewed the SAMC/SAPC findings. The ALJ wrote: “The [State Agency] physicians opined that the claimant did not have sufficient evidence to establish that he had a severe impairment.”⁶ (Tr. 21.) The ALJ stated that these opinions were unpersuasive because they were “inconsistent with subsequently added medical evidence and the record as a whole, which showed that the claimant has pulmonary sarcoidosis associated with shortness of breath, and GERD associated with reflux, nausea, and vomiting.” (Tr. 21.)

At step four, the ALJ determined that through the date last insured, Plaintiff was unable to perform any past relevant work, which was classified as medium. (Tr. 21.) At step five, he concluded that there were jobs that existed in significant numbers in the national economy that Plaintiff could have performed. (Tr. 22.) Based on the VE's testimony at the hearing, Plaintiff could have performed the jobs of office helper, small products assembler, or merchandise marker (165,000 jobs nationally in total). (Tr. 22.) Thus, the ALJ found that Plaintiff was not under a disability at any time from the alleged onset date of October 1, 2017, through the date of last insured on September 30, 2023. (Tr. 22–23.)

The Appeals Council denied Plaintiff's request for review on August 9, 2024. (Tr. 1–4.) Plaintiff then requested judicial review by filing this case on October 6, 2024 [#1].

IV. Analysis

In this appeal, Plaintiff argues (1) that the ALJ improperly ignored two state agency consultants' opinions and (2) that the ALJ failed to assist Plaintiff in developing the record, despite two state agency consultant opinions stating there was insufficient evidence in the record, and instead crafted an RFC without the support of any medical opinions. (Pl. Br. [#10], at 3.) The Court agrees with Plaintiff that the ALJ erred in making an RFC determination based on his own interpretation of the medical evidence, rather than developing the record. This error was not harmless. Accordingly, the Court will vacate the Commissioner's decision finding Plaintiff not disabled and remand for further proceedings consistent with this opinion. The Court need not reach Plaintiff's first point of error.

An RFC determination is the most an individual can still do despite his limitations. 20 C.F.R. § 404.1545(a)(1). In assessing a claimant's RFC, the ALJ must consider all the evidence in the record, including the limiting effects of all documented impairments, regardless of whether those impairments are severe or non-severe. Id. § 404.1545(a)(1)–(3). ALJs are given the “sole responsibility” to make RFC determinations, and they are “free to reject the opinion of any physician when the evidence supports a contrary conclusion.” Taylor v. Astrue, 706 F.3d 600, 602–03 (5th Cir. 2012) (citing Ripley v. Chater, 67 F.3d 552, 557 (5th Cir. 1995)); Newton v. Apfel, 209 F.3d 448, 455 (quoting Paul v. Shalala, 29 F.3d 208, 211 (5th Cir. 1994)). Their RFC determination need not mirror a physician's opinion. Miller v. Kijakazi, No. 22-60541, 2023 WL 234773, at *4 (5th Cir. Jan. 18, 2023) (per curiam).

Yet, the Fifth Circuit has made clear that an ALJ “may not—without opinions from medical experts—derive the applicant's residual functional capacity based solely on the evidence of his or her claimed medical conditions.” Williams v. Astrue, 355 F. App'x 828, 832 n.6 (5th Cir. 2009) (citing Ripley, 67 F.3d at 557). Rather, the ALJ has a “duty to develop the facts fully and fairly relating to an applicant's claim for disability benefits.” Ripley, 67 F.3d at 557. See also Sims v. Apfel, 530 U.S. 103, 111 (2000) (“It is the ALJ's duty to investigate the facts and develop arguments both for and against granting benefits․”). Where an ALJ crafts an RFC without a medical statement from a physician regarding the effects of the claimant's conditions on his ability to work, such that the only evidence regarding the plaintiff's ability to work comes from the plaintiff's own testimony, the ALJ's decision is not supported by substantial evidence. Ripley, 67 F.3d at 557–58.

Numerous district courts, including this Court, have relied on this principle in vacating RFC determinations that are not supported by an actual medical opinion and instead are based on the ALJ's subjective interpretation of the medical data in the record. See, e.g., Tiede v. Dudek, 770 F. Supp. 3d 965, 971–73 (W.D. Tex. 2025) (vacating the Commissioner's decision where there was no medical opinion regarding the plaintiff's ability to work and the sole evidence regarding her ability to work came from her own testimony); Griffin v. O'Malley, No. SA-23-CV-01090-FB-ESC, 2025 WL 440284, at *7–9 (W.D. Tex. Jan. 17, 2025), report and recommendation adopted sub nom. Griffin v. Colvin, No. SA-23-CV-1090-FB, 2025 WL 440281 (W.D. Tex. Feb. 7, 2025) (same); Raper v. Colvin, 262 F. Supp. 3d 415, 422–23 (N.D. Tex. 2017) (finding the ALJ's RFC determination to be unsupported by substantial evidence under Ripley); Fitzpatrick v. Colvin, No. 3:15-CV-3202-D, 2016 WL 1258477, at *8 (N.D. Tex. Mar. 31, 2016) (“[T]he ALJ improperly made an independent RFC finding after declining to rely on any of the medical opinions addressing the effects of [the plaintiff's] mental impairments on his ability to work.”); Thornhill v. Colvin, No. 3:14-CV-335-M, 2015 WL 232844, at *10 (N.D. Tex. Jan. 16, 2015) (“While the ALJ may choose to reject medical sources' opinions, he cannot then independently decide the effects of Plaintiff's mental impairments on her ability to perform work-related activities, as that is prohibited by Ripley ․”). If “the ALJ rejects the only medical opinions of record, interprets the raw medical data, and imposes a different RFC, the ALJ has committed reversible error.” Garcia v. Berryhill, No. EP-17-cv-00263-ATB, 2018 WL 1513688, at *2 (W.D. Tex. Mar. 27, 2018) (citing Williams, 355 F. App'x at 831); see also Beachum v. Berryhill, No. 1:17-cv-00095-AWA, 2018 WL 4560214, at *4 (W.D. Tex. Sept. 21, 2018) (citing Garcia, 2018 WL 1513688, at *2) (vacating the Commissioner's decision where the ALJ rejected all medical opinions and relied solely on “raw medical data” in crafting an RFC).

In this case, the ALJ explicitly rejected the SAMCs' and SAPCs' opinions on the grounds that they are “inconsistent with subsequently added medical evidence and the record as a whole.” (Tr. 21 (emphasis added).) On its own, his rejection of their opinions is not error. See Newton, 209 F.3d at 455 (citing Paul, 29 F.3d at 211) (“The ALJ is free to reject the opinion of any physician when the evidence supports a contrary conclusion.”). The problem is that no medical doctor ever considered the newly submitted evidence, but the ALJ nevertheless used that evidence to craft the RFC. It is error under Ripley for the ALJ to “impermissibly rel[y] on his own medical opinions as to the limitations presented by” Plaintiff's conditions, rather than seeking an opinion from a medical expert.⁷ See Williams, 355 F. App'x at 832, 832 n.6 (citing Ripley, 67 F.3d at 557). Cf. Frank v. Barnhart, 326 F.3d 618, 621–22 (5th Cir. 2003) (citing Schmidt v. Sullivan, 914 F.2d 117, 118 (7th Cir. 1990) (cautioning ALJs to not “play[ ] doctor” and “make[ ] independent medical assessments”); Salmond v. Berryhill, 892 F.3d 812, 818 (5th Cir. 2018) (quoting Morales v. Apfel, 225 F.3d 310, 319 (3d Cir. 2000) (agreeing with the Third Circuit's statement that “the principle that an ALJ should not substitute his lay opinion for the medical opinion of experts is especially profound in a case involving a mental disability”).

Moreover, the ALJ's decision was not otherwise supported by substantial evidence. The ALJ did not consider the initial-level SAMC's and SAPC's opinions, which he mischaracterized in his opinion, as conceded by the Commissioner at the hearing held before the Court on June 6, 2025. The reconsideration-level SAMC and SAPC each found “insufficient evidence” to determine Plaintiff's functional abilities.⁸ (Tr. 86, 88.) Dr. Moore's earlier psychological consultative exam did not include a suggestion as to Plaintiff's mental residual functional capacity. (Tr. 2687–2703.) The ALJ therefore did not rely on any medical evidence in the record supporting “the effect [Plaintiff's] condition had on his ability to work.” See Ripley, 67 F.3d at 557. Like in Ripley itself, the only evidence regarding Plaintiff's ability to work is his own testimony, which the Fifth Circuit held is not substantial evidence. See id.; see also Raper, 262 F. Supp. 3d at 422–23 (collecting cases in this Circuit of courts reversing based on this issue).

The Commissioner argues in response that there is no statutory or regulatory requirement for an ALJ to order a consultative examination, medical expert testimony, or updated findings from a state agency consultant. (Comm'r Br. [#14], at 5.) Instead, contends the Commissioner, the decision to do so is discretionary “and, even then, only if the ALJ finds insufficient evidence to make a decision on plaintiff's claim.” (Comm'r Br. [#14], at 5 (citing 20 C.F.R. §§ 404.1520b(b), 404.1519a).) According to the Commissioner, this duty was not triggered because there was substantial evidence, including over 9000 pages of medical evidence. (Comm'r Br. [#14], at 5.) And, after acknowledging that the reconsideration-level state agency consultants found insufficient evidence to make a medical determination, the Commissioner points to Plaintiff's failure to cooperate with the agency, citing non-binding cases holding that the absence of a medical source statement about a plaintiff's ability to work does not, by itself, make the record incomplete. (Comm'r Br. [#14], at 5–6 (citing A.G. v. O'Malley, No. 3:24-cv-266-S-BR, 2024 WL 4137269, at *3 (N.D. Tex. Aug. 13, 2024); Wills v. Kijakazi, No. 22-20609, 2023 WL 4015174, at *3 (5th Cir. June 14, 2023) (per curiam)).)

The Court disagrees that the mere existence of 9000 pages of medical records means that the ALJ's decision is supported by substantial evidence. The sheer volume of records in a case cannot make up for the fact that the ALJ did not rely on any medical opinion—except his own—in assessing Plaintiff's newly submitted medical evidence. Indeed, in Ripley itself, the Fifth Circuit explained that although “[t]he record includes a vast amount of medical evidence establishing that [the plaintiff] has a problem with his back,” the record nevertheless “d[id] not clearly establish ․ the effect [the plaintiff's] condition had on his ability to work.” Ripley, 67 F.3d at 557 (emphasis added). The same is true here. Moreover, the Commissioner is correct that a medical source statement in particular was not required. But some additional medical opinion evidence, regardless of specific form, was required such that the ALJ did not “impermissibly rel[y] on his own medical opinions.” See Williams, 355 F. App'x at 832, 832 n.6 (citing Ripley, 67 F.3d at 557) (“In Ripley, we held that an ALJ may not—without opinions from medical experts—derive the applicant's residual functional capacity based solely on the evidence of his or her claimed medical conditions.”). The ALJ's failure to utilize one of his many options to develop the record—e.g., a consultive examination, a medical source statement, an evaluation of the new records by state agency consultants, a treating source opinion, medical expert testimony, or medical expert interrogatories—was error.

Finally, Plaintiff has sufficiently demonstrated that the ALJ's error was not harmless. Reversal is only appropriate if there is prejudice from the failure to request additional information. Newton, 209 F.3d at 458 (citing Ripley, 67 F.3d at 557). “Prejudice can be established by showing that additional evidence would have been produced if the ALJ had fully developed the record, and that the additional evidence might have led to a different decision.” Ripley, 67 F.3d at 557 n.22 (citing Kane v. Heckler, 731 F.2d 1216, 1220 (5th Cir. 1984)).

Here, had the ALJ fully and properly developed the record, there would be evidence on how Plaintiff's conditions affect his ability to work. As Plaintiff emphasized at the hearing before the Court, there are hundreds of pages of medical records that were never examined by a state agency consultant or other physician, including records from after December 20, 2022, but before September 30, 2023 (i.e., after the latest medical opinion in the record and before Plaintiff's date last insured). It is entirely plausible that an evaluation of these records would have changed the ALJ's RFC determination. For example, in August 2023, Plaintiff went to the emergency room complaining of shortness of breath and chest pain: “Pt with [history] of pulmonary sarcoidosis presents with [complaints of] abrupt onset of [nausea, diarrhea, and vomiting] and [shortness of breath] ․ [a]ccompanied with central chest pain.” (Tr. 8892.) This emergency-room visit is not discussed by the ALJ. The ALJ does reference a record from July 2023 where Plaintiff stated that he no longer had shortness of breath at rest (Tr. 9190), and the ALJ explicitly relies on that finding in determining that Plaintiff can do light work (Tr. 20)—but there is no medical opinion in the record explaining the significance of Plaintiff's ER visit for shortness of breath just one month later.

Moreover, there are a significant number of mental health records that were never analyzed by an SAPC or other physician. (Tr. 9402–9527.) The ALJ disagreed with Dr. Moore's November 2021 determination that Plaintiff has “mild to moderate” impairment of his ability to concentrate. (Tr. 21.) It is plausible that a mental health professional would have given the same recommendation that, based on those later records, Plaintiff's concentration was mildly-to-moderately impaired—or even given a more limiting opinion.⁹ See, e.g., Tr. 9444 (Plaintiff reported on September 27, 2023, that he has trouble concentrating on more than half of the days, he is tired or has little energy nearly every day, and and that his mental health problems make it “[e]xtremely difficult” for him to “do [his] work, take care of things at home, or get along with other people); Tr. 9445 (Plaintiff reported on September 27, 2023, that he feels so restless that it is hard for him to sit still on more than half of the days); Tr. 9447 (Plaintiff reported on October 11, 2023, just a few days after his date last insured, that his problems with concentration and focus make him “feel like [he's] stupid sometimes” and that he “can't have a long conversation” or “complete tasks” due to his lack of focus). And, significantly, the VE at the hearing before the ALJ stated that if Plaintiff could not focus on his work 15% of the time, he would not be able to maintain employment. (Tr. 67.) Thus, additional medical opinions—regardless of the exact form of those opinions—could have led to a more limiting RFC, which could have resulted in a determination that Plaintiff is disabled at step five. See Ripley, 67 F.3d at 557 n.22. Plaintiff was therefore prejudiced by the ALJ's error, and reversal is appropriate. See id. at 557, 557 n.22.

V. Conclusion

Based on the foregoing, the Court finds that the ALJ erred by failing to develop the record and determining Plaintiff's RFC without the support of any medical opinions as to his conditions' effect on his ability to work and without any medical professional's analysis of the medical records submitted after the state agency consultants' review. Because this error could have affected the outcome of the proceedings,

IT IS HEREBY ORDERED that the Commissioner's decision finding that Plaintiff Steven Sprowl is not disabled is VACATED and this case REMANDED for further fact-finding consistent with this opinion.

IT IS SO ORDERED.

SIGNED this 6th day of August, 2025.

FOOTNOTES

1.   In this case, because the Appeals Council declined to review the ALJ's decision, the decision of the ALJ constitutes the final decision of the Commissioner, and the ALJ's factual findings and legal conclusions are imputed to the Commissioner. See Higginbotham v. Barnhart, 405 F.3d 332, 336 (5th Cir. 2005); Harris v. Apfel, 209 F.3d 413, 414 (5th Cir. 2000).

2.   His exact job was a “chemical, bio, radiological, nuclear, non-commissioned officer specialist” in the military. (Tr. 64.) According to the Vocational Expert at the hearing before the ALJ, who performed a military skills transfer analysis, “decontaminator” is the closest job in the DOT. (Tr. 64.)

3.   The PRT is the method used for evaluating mental impairments at all levels of the administrative review process. The four functional criteria considered as part of the PRT, also called the “Paragraph B criteria,” are: (1) understand, remember, or apply information; (2) interact with others; (3) concentrate, persist, or maintain pace; and (4) adapt or manage oneself. 20 C.F.R. § 404.1520a(c)(3).

4.   The reconsideration-level SAMC wrote: “Unable to complete medical determination due to insufficient evidence. The clmt and Legal Representative did not return a current 3373, provide current treating sources or respond despite multiple attempts to contact. Therefore, current functional status, residual functional status, and residual severity of impairment cannot be determined.” (Tr. 86.) The reconsideration-level SAPC wrote: “Unable to complete medical determination due to insufficient evidence. The CLMT and Legal Representative have not provided current treating sources or responded despite multiple attempts to contact. Therefore, current functional status, residual functional status, and residual severity of impairment cannot be determined.” (Tr. 88.)

5.   The ALJ specifically determined that his depression and anxiety, considered singly and in combination, were non-severe. (Tr. 17.)

6.   As the Commissioner conceded at the hearing on June 6, 2025, the ALJ was mistaken in stating that the initial-level SAMC/SAPC found insufficient evidence. Only the reconsideration-level SAMC/SAPC found insufficient evidence in the record.

7.   The Commissioner himself concedes that “the ALJ in this case didn't rely on the findings of the state agency consultants.” (Comm'r Br. [#14], at 6.)

8.   As detailed in Section III, supra, the reconsideration-level SAMC found insufficient evidence to determine Plaintiff's “current functional status” or “residual functional status,” but nonetheless subsequently recommended that Plaintiff could perform light work. (Tr. 86, 89.) The ALJ did not address or acknowledge the inconsistent recommendation of light work.

9.   In fact, the initial-level SAPC—whose opinion the ALJ mistakenly ignored—did give a more limiting recommendation than Dr. Moore. The initial-level SAPC determined that Plaintiff is moderately limited in his abilities to concentrate and adapt. (Tr. 77.) He also found that Plaintiff is moderately limited in his “ability to respond appropriately to changes in the work setting,” in his “ability to set realistic goals or make plans independently of others,” and in his “ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods.” (Tr. 80.)

ELIZABETH S. (“BETSY”) CHESTNEY UNITED STATES MAGISTRATE JUDGE